Name:
MOTT COMMUNITY COLLEGE
DIVISION OF HEALTH SCIENCES - NURSING PROGRAMS
CLIENT CARE CLINICAL FOCUS – NRSG 110
Client Initials
Age
Gender
Room #
Dates of Care
Admitting Diagnosis (es):
Past Medical History:
Allergies:
1.
Define the client’s current medical diagnosis (es) and/or surgical procedure (s).
2.
Based upon readings, list the signs and symptoms for a client with this medical diagnosis (es) and/or postoperative observations for the surgical procedure (s). At the end of the time you care for this client,
highlight or star (*) the signs and symptoms you have observed in this client.
Reference (s) of the above:
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3.
Date
List the CBC, electrolytes, and one other laboratory test for your client.
Lab
Normal Range
Client Results
Reason for Test
Nursing Interventions for abnormal results
(Include notification of health team members.)
WBC
RBC
HGB
HCT
PLAT
Na
K
CO2
Cl
BUN
Cr
Glucose
PT
PTT
INR
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4.
Date
List any diagnostic tests ordered for your client (i.e. X-ray, MRI, or CT).
Test
Client Results
Reason for Test
Preparation Pre- & Post-
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5.
Describe the anticipated nursing interventions and rationales to be used in the care of a client with this
medical diagnosis and/or surgical procedure (s). Remember to include teaching and discharge planning,
when appropriate. Include care of invasive lines and treatments such as wound care.
Intervention
Rationale (Scientific Explanation)
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6.
Describe all prescribed medications and IV solutions, including those with additives.
Drug, Dose, Route,
and Frequency
Usual and maximum
dose.
Include 24 hr range, if
available.
Drug Classification
and Action
Nursing Implications
(What must you
check or do prior to
administering this
medication?)
and
Major Side Effects
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Why is this client
receiving this drug?
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